Intern. J. Neuroscience 1979, Vol. 9, pp. 63-70

0 Gordon and Breach Science Publishers Ltd., 1979 Printed in Great Britain

RELATIONSHIP OF AGE AND EDUCATION TO PERFORMANCE ON A STANDARDIZED VERSION OF LURIA’S

NEUROPSYCHOLOGICAL TESTS IN DIFFERENT PATIENT POPULATIONS

GREGORY A. MARVEL University of South Dakota

CHARLES J. GOLDEN University of Nebraska Medical Centre

and

THOMAS HAMMEKE, ARNOLD PURISCH and DAVID OSMON University of South Dakota

(Received September 10, 1978; in fino1 form October 5, 1978)

A. R. Luria. a Russian neuropsychologist, developed many qualitative bedside tests that have been effective in the diagnosis and localization of neurological disorders. Recently, a standardized and objectively-scored version of Luria’s tests has been developed. Knowledge of the effects of patient age and education on neuro- psychological test performance has been found crucial in the neurodiagnostic decision-making process. The present study Examined the effects of patient age (younger subjects between 20 and 40 years and older subjects between SO and 70 years of age), education (grade school, high school, and post-high school), and diagnosis (normal, schizophrenic, brain damaged) on 14 standardized Luria measures. A weighted means analysis of variance found 11 significant age effects, 14 significant educational effects, and 14 significant effects for diag- nosis. One significant interaction was found between education and diagnosis, The results support the con- tention that with appropriate age and educational corrections, the standardized Luria battery would satisfy the need for a short, objectively scored, and diagnostically effective neuropsychological battery.

Aleksandr Romanovich Luria, the late, noted Russian neuropsychologist, developed and refined many qualitative bedside tests to be administered to brain-injured patients. He (1966, 1973) reported that these tests are highly effective in the diagnosis of brain damage and in the localization of neuro- logical disorders.

Christiansen (1975a,b,c) has recently published the Luria Neuropsychological Investigation, which consists of the test and procedures needed to con- duct Luria’s tests. The Luria battery has several advantages over other test batteries: it is com- prehensive, it requires about 24 hours to administer, compared with six to eight hours for some test batteries, it is portable, it uses far less expensive equipment than other comprehensive procedures, and it yields qualitative evaluations.

However, Christiansen’s version of the Luria battery does have several faults. The test does not

include instructions for standardized administration or objective scoring. Standardized administration permits comparison of test results across patients without the confounding influences of personal style of administration. Objective scoring permits the establishment of norms against which indi- vidual performances are measured or compared. Many researchers have felt that the addition of standardized procedures and objective scoring would increase the value of Luria’s tests (Golden, 1977a).

THE NEUROPSYCHOLOGICAL BATTERY

To fill the need for a short, standardized, objectively scored version of the Luria battery, Golden, Hammeke, and Purisch (in press) recently adapted some of the qualitative tests from Christiansen’s

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64 G. A. MARVEL ef al.

(1 975a,b,c) Luria Neuropsychological Investigation to develop an objective form of the Luria Neuro- psychological battery. The battery is composed of 269 measures that assess 11 major areas of neuro- psychological performance. I t can be administered in about 24 hours and requires only a few pieces of small and inexpensive equipment.

Research with the Standardized Luria Battery has demonstrated its utility. In a study by Golden et al. (in press), it was shown that 252 of the 269 Standardized Luria measures significantly differ- entiated brain-damaged from medical-control patients. In another study by Hammeke el al. (in press), it was found that 14 summary scores derived from the battery could significantly differentiate between the control and brain-damaged groups. Ninety-three per cent of the patients were correctly classified using a discriminant analysis. Purisch el al. (in press) were able to classify correctly 88 % of a patient group composed of equal numbers of schizophrenic and brain-damaged patients. How- ever, this initial research used groups matched on age and education. Consequently, the effects of patient age and education have not been evaluated.

Numerous clinicians have emphasized the import- ance of knowing the effects of age and education on neuropsychological test performance (e.g., Golden, 1978; Golden & Schlutter, 1978; Mathews & Kiernan, 1976; Prigatano & Parsons, 1976; Vega & Parsons, 1967). The arguments for determining such effects have been along two major lines : the substantial age and education effects on neuropsychological test results independ- ent of a patient’s diagnosis, and the usefulness of knowing these effects in diagnostic work.

AGE

Several recent studies have attempted to determine the effect of age on the neuropsychological test performances of normal and brain-damaged per- sons. Many of these studies have employed either the Halstead Battery (Halstead, 1947) or Reitan’s modification, the Halstead-Reitan Neuropsycho- logical Battery (Reitan & Davison, 1974).

Using the Halstead Battery, Reitan (1955) found a small correlation ( r = 0.23, N = 194) between the degree of brain impairment and age in the brain-damaged group but a rather high correlation ( r = 0.54, N = 133) in the non-brain-damaged group. Reitan concluded that, in the normal group, increasing deficits on neuropsychological tasks

with increasing age probably reflects brain impair- ments. Reitan noted that these impairments seem to appear rather abruptly within the 45 to 50 year old age group.

In two later studies (Fitzhugh, Fitzhugh & Reitan, 1964; Reed & Reitan, 1963), age was again found to be positively correlated with neuro- psychological deficits in both normal and brain- damaged groups. However, in a study by Vega & Parsons (1967), the positive correlation between the neuropsychological deficits and age was smaller in the brain-damaged group ( r = 0.33) than in the medical-surgical control group ( r = 0.57).

In a cross-validation study of Vega and Parsons’ earlier (1967) study, Prigatano & Parsons (1976) investigated which Halstead tests exhibited age effects in a brain-damaged group and a psychiatric control group. As in the earlier Vega & Parsons (1967) study, the positive correlation between neuropsychological deficit and age was smaller in the brain-damaged group ( r = 0.44) than in the psychiatric control group (r = 0.64). Age was significantly correlated with the same neuropsycho- logical measures in the new psychiatric control group as in the old medical-surgical control group.

A recent study by Golden & Schlutter (1978), using an analysis of variance design, provided evidence that age effects are identical in control and brain-damaged groups. They found no signifi- cant interaction effects between age and diagnosis on 15 neuropsychological measures. These results conflict with the results of the earlier reported studies which describe different correlations in normal and brain-damaged groups. Golden & Schlutter (1978) believe that the differences in correlations are a consequence of small sample sizes and the failure to test for the significance of the difference between correlations. This lack of interaction between age and diagnosis suggests that relatively simple age corrections may be used for specific neuropsychological tests irrespective of diagnosis.

EDUCATION

Very few studies have investigated the effect of education on the neuropsychological test perform- ances of normal and brain-damaged subjects. Vega & Parsons (1967) demonstrated that education was significantly correlated with six measures from the Halstead-Reitan Battery (Category Test, Tactual Performance Test-Time, Seashore Rhythm Test,

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RELATIONSHIP OF AGE A N D EDUCATION 65

Speech Perception Test, Finger Tapping, and Impairment Index) in a control (medical-surgical) population only. In a recent cross-validation study of Vega & Parsons’ earlier (1967) study, Prigatano & Parsons (1976) found that education was signific- antly correlated with only one measure in one group, the Seashore Rhythm Test in the brain-damaged group.

Benton, Levin & Van Allen (1974), using an analysis of variance design, found that education exerted a main effect on a test of geographic orient- ation in both control and brain-damaged groups. They also reported a significant interaction between education and diagnosis. The brain-damaged, low education group performed much worse relative to the control, low education group than did the brain-damaged, high education group relative to the control, high education group.

Finlayson, Johnson & Reitan (1977) found a modest influence of education on neuropsycho- logical test performances. Levels of education (grade school, high school, three or more years of college) have a significant main effect for all of the Wechsler Bellevue subtests except for the Object Assembly test. Across diagnoses, the higher the education, the better the performance. Interaction effects between level of education and diagnosis (brain-damaged or control) were found for Per- formance IQ, Vocabulary, and Digit Symbol. On these three dependent measures, the brain-damaged, university group performed poorer relative to its control group than did the other brain-damaged groups with lower education. In the same study (Finlayson et al. 1977), level of education had a significant main effect on only five of ten Halstead- Reitan measures (Category Test, Seashore Rhythm Test, Speech Perception Test, Trail Making Test- Part A, and Trail Making Test-Part B). For these five measures, across diagnoses, the higher the education, the better the performance. No signifi- ant interactions between education and diagnosis were found for the Halstead-Reitan measures.

DIAGNOSTIC ROLE OF AGE AND EDUCATION

Determining the contribution of patient age and education to neuropsychological test performance allows for a reduction in error variance and enables the clinician more confidently to diagnose a given sase (Golden, 1977a). If a neuropsychological test battery is to be generally useful in “uncontrolled‘’

situations, knowledge of age and education effects is necessary to assure accuracy in diagnosing patients with different educational backgrounds and in different age groups.

For example, a significant main effect for age may heavily influence a diagnostic decision. Even if a 75 year old patient performs much worse on a test battery relative to the average of 25 year old persons, age norms for normal subjects may indicate that this older patient is expected to perform much worse than younger persons. Therefore, knowledge of age effects can reduce the clinician’s probability of making a false positive diagnosis (diagnosis of brain-damage where none, in fact, exists).

A main effect for education could also influence the diagnostic decision. If a college professor per- formed comparably with normal adults who have only grade school educations, educational norms might indicate that a better performance is expected of the college professor, enabling a clinician to diagnose brain damage from ostensibly “normal” performance. Therefore, knowledge of educational effects can reduce the clinician’s probability of making a false negative diagnosis (diagnosis of brain integrity where damage, in fact, exists).

PRESENT STUDY

In light of the research, it is clear that both age and education are potentially significant factors in neuropsychological results. When they do play a role in the test results, they can significantly affect the diagnostic process. Consequently, it is import- ant that age and education effects be available for any neuropsychological battery.

The present study is an attempt to investigate the effects of age and education on the performance of three diagnostic groups (brain-damaged, schizo- phrenic, control) on the Standardized Luria Neuropsychological Battery. This study allows us to examine both the simple effects of age and education on the Luria variables and any inter- actions between age, education, and diagnosis.

METHOD

Subjects

The 269 subjects for this study were selected from hospitalized patients is Sioux Falls, South Dakota; Yankton, South Dakota; and Sioux City, Iowa.

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66 G. A. MARVEL et al.

Written permission to participate in this study was obtained from each patient. Control (normal) subjects were hospitalized patients without brain injury. Schizophrenic subjects received their diag- nosis from Institutional (hospital) physicians. Brain-damaged subjects received a confirmed diagnosis of brain damage from a neurologist or neurosurgeon. Those subjects whose brain-damage occurred before age 15 were excluded from the study.

Procedure

The complete Standardized Luria Neuropsycho- logical Battery as developed by Golden, Hammeke & Purisch (in press) was administered to all subjects. Administration and scoring of the battery followed the procedures developed by the above authors.

Subjects were assigned to one of eighteen cells depending on their age, education, and diagnosis. The factor of age had two levels, one for subjects between 20 and 40 years of age and one for subjects between 50 and 70 years of age. Reitan (1955) has provided some evidence that brain impairment seemstoappear rather abruptly near age 45. The above two age groups were chosen because it was felt that age cutoffs of five years on either side of age 45 would separate and highlight the differences more optimally between these two groups. The factor of education had three levels, one for sub- jects with formal educations of less than 10 years, one for subjects with education greater than or equal to 10 years but less than 13 years, and one for subjects with education greater than or equal to 13 years. Descriptive information on these groups is contained in Table I. The factor of

TABLE I Descriptive variables of subjects

M SD n _____ Age in years

Younger group 29.3 3.8 135

Older group 56.4 4.5 136

Years of education

Grade school 6.7 I .6 88

High school 10.8 1.2 93

Post-high school 14.5 1.8 90

diagnosis had three levels: control, schizophrenic, and brain-damaged.

Materials

The Standardized Luria Neuropsychological Battery requires several pieces of equipment (Golden, 1977b): (a) a series of cards and pictures published by Christiansen (1975~); (b) additional pictures used to replace some of the Christiansen items; (c) a 13 cm black comb; (d) a 2 4 x & inch rubber band; (e) a jumbo-sized paper clip; (f) a Vox Compass No. 5178, available from Empire Pencil Company, Shelby, Tennessee 37160; (g) a Pedigree Quality Eraser No. 2910, also available from the Empire Pencil Company; (h) a key (Wr@ Curtiss 177); (i) a straight pin; (j) a quarter; (k) a metric ruler; (I) an audio tape from some of the verbal and rhythm items.

The Standardized Luria Neuropsychological Battery consists of 269 measures. The items fall into eleven categories:

Motor functions This category includes tasks that require reproduction and repetition of simple hand, mouth, lip, and tongue movements with verbal and modeled instructions and with verbal instructions only. This category also includes simple coordination tasks, optical-spatial tasks, sequencing and drawing.

Rhythm (acoutico-motor) functions This category includes tasks that require pitch and rhythmic differentiation of sounds as well as reproduction of rhythms, pitches and melodies heard on a tape recorder.

Tactile (cutancow and kinesthetic) funcfions This category includes tasks that evaluate stereognostic, cutaneous, kinesthetic, and proprioceptive func- tions. Kinesthetic-proprioceptive assessment requires a blindfolded subject to identify the direction of limb and finger movements and to reproduce limb positions. Cutaneous assessment includes evaluation of threshold, localization, stimulus identification, and two points finger discrimination. Stereognostic assessment requires a blindfolded subject t o identify common objects placed in the palm of the hand under both active and passive touching conditions.

Visual functions This category assesses the integ- rity of visual-spatial perception, including the identification of pictures and objects. The identifi- cation of missing elements in complex geometrical

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RELATIONSHIP OF AGE AND EDUCATION 67

configurations and the construction of geometric patterns from blocks are tasks that are also included. Subjects must identify time on clocks with no numbers and show spatial and directional orient- ation. The ability to perform spatial rotations and transformations is assessed.

Rereprice (impressive) speech The category assesses a subject’s ability to discriminate basic English phonemes, and to reproduce the discrimin- ations orally or by writing, to name familiar and unfamiliar objects among a series of pictures, and to respond to statements and questions that require the understanding of genitive, prepositional, comparative, and complex grammatical con- structions.

Expressive speech This category includes tasks that require the articulation of simple speech sounds, familiar and unfamiliar words, and phrases or sentences of various lengths and complexity. Tasks that require naming and classification of objects and production of narrative descriptions are also included.

Reading This category includes tasks that require the subject to break words into their component sounds or letters, to synthesize words from sounds or letters, and to read syllables, words, phrases, and paragraphs . Writing This category includes tasks that require the subject to copy letters and words and to write words from dictation.

Arithmetic skills This category requires the identi- fication of Arabic and Roman numerals, the identi- fication of the significance of digit placement, the comparison of large and small numbers, arithmetic operations, algebraic manipulations, and the for- mation of arithmetic series. Items are presented both orally and visually.

Memory (mnestic) processes This category assesses an individual’s retention and retrieval skills for visual, acoustic, and kinesthetic inputs. Subjects must work with both verbal and nonverbal material The effects of retroactive and proactive interference. are also examined. Intellectual processes This category requires the subject to interpret the themes of pictures, to demonstrate vocabulary skills, to form concepts, to classify objects, to understand analogies, to understand complex arithmetical problems, and Lo show logical reasoning abilities.

Scoring Raw scores on all items were scored on a three-point (0, 1, 2) scale as developed by Golden, Hammeke, and Purisch (1977b). A scaled score of 0 represents the performance characteristic of a normal individual. A scaled score of 1 represents an intermediate level of performance found in both brain-damaged and normal individuals. A scaled score of 2 represents the performance characteristic of brain-damaged subjects.

Summary scoring indices The scores of the items in each section were summed to yield a summary index for that neuropsychological category or function. Eleven summary indices were created in this way.

Three other scoring indices from the Standard- ized Luria Battery were included : pathognomonic index (sum of the 34 most effective indicators of brain damage), left-hemisphere (sum of all items which require right hand performance alone), and right hemisphere (sum of all items which require left hand performance alone).

RESULTS

Since the number of subjects assigned to each cell was different (cell size varied from 12 to 18), a weighted means analysis of variance procedure was used so that each cell would contribute equally to the overall F ratios. This procedure assigns weight to each cell equal to the harmonic mean of the individual cell sizes. For this sample, the harmonic mean was 14.94.

Table I1 presents the results of the weighted means analysis of variance for each measure in- cluded in the study. As can be seen, eleven of the fourteen measures showed significant age effects. Across diagnoses and educational levels, the higher the age the poorer the performance on those eleven standardized Luria battery measures.

Education (whether grade school, high school, or post-high school) accounted for a significant amount of variance in all 14 of the standardized Luria measures. In general, across diagnoses and ages, the higher the education, the better the performance on the neuropsychological measures.

The results also indicate that diagnosis accounts for a significant amount of variance in all 14 standardized Luria measures. This is consistent with past research (Purisch, 1977; Hammeke, 1977) demonstrating the neurodiagnostic utility of the standardized version of the Luria battery.

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68 G . A. MARVEL et a/.

TABLE I1 F ratios for the effects of age, education, and diagnosis and their interactions

F’s Variable Age (A)d Education (B)= Diagnosis (C). AXCe BXCf AXBe AXBXCf

Motor Rhythm Tactile Visual Receptive Expressive Reading Writing Arithmetic Memory Intelligence Pathognomon Right Left

18.55’. 6.11**

31.76’’ 23.96’. 14.22.. 8.77. 1.18 0.15 0.64

14.411’ 3.77‘

iic 34.64.. 20.34.. 20.63..

6.91.. 11.78.. 3.25. 8.80’. 9.08’.

17.12.’ 22.04.. 28.24.’ 20.56.. 6.24.

14.79.‘ 11.04** 4.80‘ 4.80.

24.93.. 29.51.. 19.80.. 23.41..

16.66’. 13.17. 12.38.. 13.78.. 32.49.. 23.32.. 35.60’. 17.92.. 18.97..

24.48-

0.16 0.81 0.30 0.61 1.45 I .78 0.07 0.87 0.69 0.29 0.62 0.20 0.25 1.96 0.50 0.24 1.69 0.17 2.67 2.71. 0.17 0.94 0.56 1.42 0.32 1.95 0.50 0.95 I .04 0.46 0.44 1.32 1.38 0.37 0.93 0.01 0.00 0.46 0.69 0.19 0.80 0.00

~~

0.30 0.90 0.83 0.26 0.49 0.35 I .01 0.80 1.03 0.57 1.86 0.51 0.04 0.55

One significant interaction was found, that be- tween education and diagnosis for the reading measure. With an alpha of 0.05, one would have expected a t least 4 significant interactions to appear purely by chance out of the 94 possible interactions. Therefore, it may be that the interaction of edu- cation and diagnosis for the reading measure is spurious.

DISCUSSION

The age effects for most of the standardized Luria measures seem to be rather compellingly explained in terms of Cattell’s (1968, 1964) theory of “fluid” and “crystallized” general ability. “Crystallized” abilities are involved in those cognitive skills or judgments that rely heavily on earlier learning, earlier practice, or previously stored information. Crystallized abilities, then, draw upon much rote learning and established habit. “Fluid” abilities, on the other hand, are involved in those skills that require active problem-solving or adaptation to new or unique situations. Fluid abilities, then, reflect flexibility and a certain measure of creative insight into solutions to problems or approaches to tasks.

Cattell (1964) felt that fluid abilities increase from birth to about age 15, remain constant until about age 22, and then decline continuously to old age. However, he felt that crystallized abilities display a stcady increase until formal education or self-study ceases (anytime from about age 18 to 28) and then

decline. According to Cattell, the drop in crystal- lized abilities is later and less severe than the drop in fluid abilities.

In light of Cattell’s theory, one would expect that those standardized Luria neuropsychological measures that appear to rely on crystallized abilities would show few, if any, age effects because the drop in these abilities over the years would be rather slight. However, those measures that seem to rely on fluid abilities should show significant age effects because the drop in these abilities over the years would be rather great. The results seem to bear out these conclusions. The following standard- ized Luria measures appear to rely upon the crystal- lized intellectual abilities of rote learning, infor- mation recall, and established habit: Reading, Writing, and Arithmetic. In each case no significant age effects were found, which provides some support for Cattell’s theory that crystallized abilities show little loss with increasing age.

The following standardized Luria measures appeear to rely upon the fluid intellectual abilities of active problem-solving and creative or flexible approaches to new tasks: Tactile, Rhythm, Visual, Motor, and Memory. In each case significant age effects were found, which provides some support for Cattell’s notion that fluid abilities decrease over time. The Receptive Speech, Intelligence, and Expressive measures appear to rely on both crystallized and fluid abilities. These too, had significant age effects.

Two of the standardized Luria summary meas- ures, Left and Right, are derived from items taken

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RELATIONSHIP OF AGE AND EDUCATION 69

from the motor and tactile sections of the battery and thus displayed significant age effects because the parent measures displayed significant age effects.

The pathognomonic measure is a summary measure derived from all of the scales. It represents items that are are the most discriminating between brain-injured persons and persons with other pathologies. The pathognomonic measure showed a significant age effect. In this respect, it is similar to Halstead’s Impairment Index, which has been shown to be positively correlated with age in both brain-damaged and non-brain-damaged groups in many of the previously reported studies.

The data on the main effects of education indicate that the difference in performance between the grade school and high school groups is much greater than the difference between the high school and post-high school groups. This finding may be explained by the fact that ninth grade and twelfth grade are distinct institutional cutoffs for education. Individuals who do not seek higher education usually stop attending school at either the ninth or twelfth grades. Thus, three years of education separate these groups. However, those who seek higher education often attend college or technical school for only one or two years. Thus, only one or two years need separate these two groups. The relative difference in years attended between these three groups is reflected in the relative difference in performance on the standardized Luria measures.

CONCLUSIONS

The results of the present study indicate that simple age correlations could be used for the eleven standardized Luria measures that showed signific- ant age effects. Such corrections would require older subjects to score more poorly relative to their peers before they could be diagnosed as brain- damaged. Since the natural aging process itself probably causes a gradual decrease in the brain’s integrity and efficiency (adversly affecting “fluid” abilities), differentiating age-related brain changes from brain damage is rather arbitrary. Older subjects, however, who perform much worse on neuropsychological tests than their age peers are more likely to have significant structural brain damage than merely age-related changes.

The results of this study also indicate that simple educational corrections could be used for the four- teen standardized Luria measures that showed

significant educational effects. Such corrections would require that more educated subjects receive scores reflecting better than average performance before dismissing the diagnosis of brain damage. Since highly educated subjects are expected to perform better than average on most standardized Luria measures, even an average score may reflect cortical damage. In contrast, educational cor- rections would require that poorly educated subjects score poorer than average to be diagnosed as brain damaged.

Finally, this study has shown the Standardized Luria Battery to be effective in distinguishing normal, schizophrenic, and brain-damaged per- formance on 14 neuropsychological measures. With appropriate age and educational corrections, the Standardized Luria Battery would satisfy the neuropsychologist’s need for a short, objectively- scored, and diagnostically-effective neuropsycho- logical battery.

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